Comorbid childhood gender identity disorder in a boy with Asperger syndrome

Abstract

IN AUTISTIC PSYCHOPATHY, Hans Asperger described that ‘the autistic personality is an extreme variant of male intelligence’.1 Consistent with this notion, Baron-Cohen proposed the ‘extreme male brain theory of autism’.2 By quoting this theory, gender dysphoria in female subjects with Asperger syndrome (AS) could be explained logically. But a literature search yielded no boys with AS and gender identity disorder (GID). Hereby we present such a case. Informed written consent was obtained from the patient's parents. A 5-year-old boy was referred to Child Psychiatry, Sapporo Ayuminosono because of his poor social skills. He had no peri-/neonatal complications. In his infancy he passed early motor and language landmarks without significant delay. Single words were developed at the age of 1 year and communicative phrases were observed at 2.2 years of age. Preoccupations with specific colors and figures were observed. He had limited interaction with others, difficulty in developing peer relationships and was underresponsive in social situations. He liked making his own rules and frequently lost his temper when these were broken. On the Wechsler Intelligence Scale for Children-III he had a full-scale IQ of 92 (verbal IQ 90, performance IQ 96) at the age of 7.6 years. Although his appearance was obviously that of a boy, he spoke in a girlish manner and covered his mouth with a hand when he laughed, as female individuals commonly do. He had very limited interaction with boys and his preferred playmates were girls. He was not interested in stereotypical boy's toys and had a marked preoccupation with feminine activities. He liked cute characters in TV animations and always painted cute girls surrounded with many lovely hearts and flowers. At home he tended to dress in girlish clothes and wear a ribbon in his hair. He regretted being a boy and often showed his desire to be a girl and asserted that he would grow up into a woman. These symptoms have been observed throughout the follow-up period of more than 2 years. Based on these symptoms, we diagnosed him as having AS and GID in accordance with the ICD-10 criteria. Most of the gender-related symptoms in autistic spectrum disorders (ASD) could be related to behavioral and psychological characteristics of autism. For example, a boy with ASD might have a sense of belonging to the female sex after being bullied by male peers. Transvestism in ASD may arise from a preoccupation with specific clothes such as a flared skirt which satisfies their tactile sensation. In their youth, ASD subjects can sometimes develop a unique confusion of identity that occasionally expands to gender-related problems. But these views do not explain the present case. For the diagnosis of GID in ASD, sufficient language abilities and sufficient follow-up time are essential. The present case fulfills these requirements. If the present patient continues to have gender-related symptoms into adulthood, we would need to treat him following an international standard.